Women s Sexual Health: STI and HIV Screening. Barbara E. Wilgus, MSN, CRNP STD/HIV Prevention Training Center at Johns Hopkins

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1 Women s Sexual Health: STI and HIV Screening Barbara E. Wilgus, MSN, CRNP STD/HIV Prevention Training Center at Johns Hopkins

2 I have no disclosures! Review most recent rates of STIs and HIV across the US Discuss CDC s STD Screening Guidelines for women Provide information about resources for creating your own sexual health protocol [even to advocate for yourself as a patient!]

3 STIs and HIV: What s Happening with Women?

4 Chlamydia Rates of Reported Cases Among Women by State, United States and Outlying Areas, 2016 NOTE: The total rate of reported cases of chlamydia among women in the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was per 100,000 females.

5 Chlamydia Rates of Reported Cases by Age Group and Sex, United States, 2016

6 Chlamydia Percentage of Reported Cases Among Women by Reporting Source*, United States, * Includes the top five reporting sources for chlamydia cases reported among women, plus those with reporting sources listed as All Other and Missing/Unknown. HMO = health maintenance organization; HD = health department. NOTE: All Other includes: Drug Treatment, Tuberculosis Clinic, Correctional Facility, Blood Bank, Labor and Delivery, Prenatal Care, National Job Training Program, School-based Clinic, Mental Health Provider, Indian Health Service, Military, Emergency Room, STD Clinic, HIV Counseling and Testing Site, and Other.

7 Gonorrhea Rates of Reported Cases Among Women by State, United States and Outlying Areas, 2016 NOTE: The total rate of reported cases of gonorrhea among women in the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was per 100,000 females.

8 Gonorrhea Rates of Reported Cases by Age Group and Sex, United States, 2016

9 Gonorrhea Rates of Reported Cases Among Women Aged Years by Age Group, United States,

10 Gonorrhea Percentage of Reported Cases Among Women by Reporting Source*, United States, * Includes the top five reporting sources for gonorrhea cases reported among women, plus those with reporting sources listed as All Other and Missing/Unknown. HMO = health maintenance organization. NOTE: All Other includes: Drug Treatment, Tuberculosis Clinic, Correctional Facility, Blood Bank, Labor and Delivery, Prenatal Care, National Job Training Program, School-based Clinic, Mental Health Provider, Indian Health Service, Military, Emergency Room, Other Health Department Clinic, HIV Counseling and Testing Site, and Other.

11 Primary and Secondary Syphilis Rates of Reported Cases Among Women by State, United States and Outlying Areas, 2016 NOTE: The total rate of reported cases of primary and secondary syphilis among women in the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was 1.9 per 100,000 females.

12 Primary and Secondary Syphilis Rates of Reported Cases by Sex and Male-to-Female Rate Ratios, United States,

13 Primary and Secondary Syphilis Rates of Reported Cases Among Women Aged Years by Age Group, United States,

14 Congenital Syphilis Rates of Reported Cases Among Infants by Year of Birth and State, United States and Outlying Areas, 2016 NOTE: The total rate of reported cases of congenital syphilis for infants by year of birth for the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was 15.7 per 100,000 live births.

15 Congenital Syphilis Reported Cases by Year of Birth and Rates of Reported Cases of Primary and Secondary Syphilis Among Women, United States, * CS = Congenital syphilis; P&S = Primary and secondary syphilis.

16 Rates of Diagnoses of HIV Infection among Female Adults and Adolescents 2016 United States and 6 Dependent Areas N = 7,639 Total Rate = 5.5 Note. Data for the year 2016 are preliminary and based on 6 months reporting delay.

17 Diagnoses of HIV Infection among Female Adults and Adolescents by Transmission Category and Age at Diagnosis 2016 United States and 6 Dependent Areas Note. Data for the year 2016 are preliminary and based on 6 months reporting delay. Data have been statistically adjusted to account for missing transmission category. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes blood transfusion, perinatal exposure, and risk factor not reported or not identified.

18 Diagnoses of HIV Infection and Population among Female Adults and Adolescents, by Race/Ethnicity, 2016 United States Note. Data for the year 2016 are preliminary and based on 6 months reporting delay. a Hispanics/Latinos can be of any race.

19 Deaths of Female Adults and Adolescents with Diagnosed HIV Infection by Race/Ethnicity, 2015 United States Note. Deaths of persons with diagnosed HIV infection may be due to any cause. Rates are per 100,000 population. a Includes Asian/Pacific Islander legacy cases. b Hispanics/Latinos can be of any race.

20 Creating Your Own Sexual Health Protocol

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22

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24 Sexual Health Protocol: History Partners Practices Protection from STIs Past history of STIs Prevention of pregnancy And, a bonus P : PLEASURE

25 STI Screening: Physical exam Visual inspection: Skin and mucous membranes [rashes, lesions, warts] Is discharge present? Note location [urethral, vaginal, cervical, rectal] and consistency [purulent, clear, cottage cheese, frothy, etc] For ASYMPTOMATIC screening: consider express testing for self collection of swabs

26 CDC Screening Guidelines: Chlamydia Women Sexually active women under 25 years of age 1 Sexually active women aged 25 years and older if at increased risk 2 Retest approximately 3 months after treatment 3 Pregnant Women All pregnant women under 25 years of age 1 Pregnant women, aged 25 and older if at increased risk 2 Retest during the 3rd trimester for women under 25 years of age or at risk 3,4 Pregnant women with chlamydial infection should have a test-of-cure 3-4 weeks after treatment and be retested within 3 months 1 Men *Consider screening young men in high prevalence clinical settings 5 or in populations with high burden of infection (e.g. MSM) 6 Men Who have Sex With Men (MSM) Persons with HIV At least annually for sexually active MSM at sites of contact (urethra, rectum) regardless of condom use 6 Every 3 to 6 months if at increased risk 7 For sexually active individuals, screen at first HIV evaluation, and at least annually thereafter8 More frequent screening for might be appropriate depending on individual risk behaviors and the local epidemiology 8 Centers for Disease Control and Prevention, 2015 STD Treatment Guidelines

27 CDC Screening Guidelines: Gonorrhea Women Sexually active women under 25 years of age 1 Sexually active women age 25 years and older if at increased risk 9 Retest 3 months after treatment 10 Pregnant Women All pregnant women under 25 years of age and older women if at increased risk11 Retest 3 months after treatment 10 Men Who have Sex With Men (MSM) At least annually for sexually active MSM at sites of contact (urethra, rectum, pharynx) regardless of condom use 10 Every 3 to 6 months if at increased risk 7 Persons with HIV For sexually active individuals, screen at first HIV evaluation, and at least annually thereafter10 More frequent screening for might be appropriate depending on individual risk behaviors and the local epidemiology 10 Centers for Disease Control and Prevention, 2015 STD Treatment Guidelines

28 Why do extragenital testing (GC and CT)? From July 2003 until February 2007, 441 rectal test sets were collected from individuals attending a sexually transmitted disease clinic and three HIV clinics who gave a history of anal intercourse or were women at high risk for Neisseria gonorrhoeae or Chlamydia trachomatis infections. Over 60% and 80% of gonococcal and chlamydial infections, respectively, among men who have sex with men and over 20% of chlamydial infections in women would have been missed if the rectal site had not been tested.* Baltimore STD clinics: among women endorsing extragenital exposures, 30.3% of GC infections and 13.8% of CT infections would have been missed with urogenital-only testing.** *Bachmann LH et al. J Clin Micro 2010: ; **Trebach et al. STD 2015.

29 CDC Screening Guidelines: Syphilis Pregnant Women All pregnant women at the first prenatal visit11 Retest early in the third trimester and at delivery if at high risk 12 Men Who have Sex With Men (MSM) At least annually for sexually active MSM 13 Every 3 to 6 months if at increased risk 7 Persons with HIV For sexually active individuals, screen at first HIV evaluation, and at least annually thereafter14,15,16 More frequent screening might be appropriate depending on individual risk behaviors and the local epidemiology 13 Centers for Disease Control and Prevention, 2015 STD Treatment Guidelines

30 CDC Screening Guidelines: HIV Women All women aged years (opt-out)** 18 All women who seek evaluation and treatment for STDs 19 Pregnant Women All pregnant women should be screened at first prenatal visit (opt-out)20 Retest in the third trimester if at high risk 21 Men All men aged (opt-out)** 18 All men who seek evaluation and treatment for STDs 19 Men Who have Sex With Men (MSM) At least annually for sexually active MSM if HIV status is unknown or negative and the patient himself or his sex partner(s) have had more than one sex partner since most recent HIV test 22 Centers for Disease Control and Prevention, 2015 STD Treatment Guidelines

31 CDC guidelines: STIs and PrEP Assess for STIs at baseline! CDC guidelines: screen MSM for STIs every 3-6 mos if at increased risk. Bacterial STDs = Gonorrhea, Chlamydia and Syphilis

32 In Summary: Rates of STIs are at an all time high, INCLUDING FOR WOMEN Rates of HIV in women, particularly women of color, should not be discounted Advocate for, and implement, a sexual health protocol that includes comprehensive history, screening, treatment, and prevention

33 Thank you! Barbara Wilgus, MSN, CRNP

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